A nurse is caring for a toddler who is 24 hr postoperative following a cleft palate repair.
Which of the following actions should the nurse take?
Apply bilateral wrist restraints.
Implement a soft diet.
Administer opioids for pain.
Offer fluids through a straw.
The Correct Answer is C
A. Applying bilateral wrist restraints is not a standard intervention after cleft palate repair.
Restraints should be used judiciously and with clear indications to prevent injury.
B. The baby can start feeding normal diet after 24hrs
C. Administering opioids for pain is an appropriate action by the nurse. Opioids control pain in the immediate postoperative period are followed by administration of acetaminophen PRN.
D. Offering fluids through a straw is contraindicated after cleft palate repair, as it can disrupt the healing process and increase the risk of complications. Sippy cups or other appropriate utensils should be used.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Projectile vomiting in an infant could be indicative of a serious condition, and advising on burping may not be sufficient. A prompt assessment by a healthcare provider is needed.
B. Projectile vomiting can be a concerning sign and may be associated with conditions such as pyloric stenosis. Bringing the baby to the clinic for evaluation is the appropriate action.
C. Switching formula may not address the underlying cause of projectile vomiting, and it is crucial to determine the cause through a thorough examination.
D. While oral rehydration solution may be used for dehydration, the priority is to assess the infant in person to determine the cause of the vomiting.
Correct Answer is C
Explanation
A. Threatening the child with a shot may create anxiety and fear, making cooperation even more challenging.
B. Hiding medication in food without the child's knowledge can lead to mistrust and may not be safe, as the child may not consume the entire dose.
C. Telling the child that the medication is candy is a strategy that may increase the likelihood of the child taking the medication willingly. However, it is important to ensure that the child understands the importance of taking the medication and that it is not actually candy.
D. Offering a choice of taking the medication with juice or water provides some control to the child, but it may not address the resistance to taking the medication itself. The child may still refuse regardless of the choice.
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